Prisons are among the most complex, restrictive organizations responsible for the care of highly vulnerable individuals;current epidemiological trends among inmate populations are surprisingly similar to those faced in the broader society. Inmates tend to be 10-15 years older physiologically than they are chronologically, resulting in their being labeled as "geriatric" in their fifties. Reflective of the larger society, geriatric inmates are the fastest-growing age-cohort in prisons. These inmates are living with and dying from chronic illness-in fact, the overwhelming majority of state prison inmate deaths in the US are attributed to chronic medical conditions. Despite their crimes, dying inmates should not end their days in pain and anguish from a poorly managed death. One of inmates'greatest fears is dying alone in prison;this context is especially harsh to those who face the end of life. This study proposes to examine relevant cost indicators and to explore the feasibility and effectiveness of applying Participatory Action Research (PAR) methodology to infuse generalist end-of-life (EOL) strategies into the complex organization of a state prison system. Specifically, we will: 1.) Compare and contrast the current status of EOL care in contextually diverse prison communities;2.) Evaluate the infusion of modified approaches to EOL care using an intervention toolkit to meet the prioritized needs identified by stakeholders in diverse correctional facilities;and, 3.) Identify resource utilization data that are most appropriate for determining cost effectiveness of modified approaches to EOL care. PAR methods extend the research team to include those who are "local" to the diverse communities being studied. In this way, both local and outsider knowledge will be used to tailor EOL strategies that fit the constraints of the prison setting. The infusion of enhanced EOL strategies will directly impact the quality of life of inmates who are suffering from advanced chronic illnesses. From a broader perspective, this study will provide important findings relevant to advancing the state of the science of EOL care by translating a model for infusing best practices into the most challenging and complex of organizations with a carefully coordinated cost analysis. PUBLIC HEALTH RELEVANCE: An innovative alternative is needed to achieve broader implementation and greater success in infusing end-of-life (EOL) care into correctional settings. Toward that end, the purpose of this project is to examine the feasibility of using Participatory Action Research for instilling generalist EOL strategies into the complex organizational system of a state Department of Corrections. This approach of enlisting the researched as co- researchers holds promise for: revealing effective strategies for overcoming barriers to accomplishing change in the delivery of health services within a highly bureaucratic system;achieving greater satisfaction for prison staff caring for inmates at the end of life;delivering more humane and cost-effective care for a particularly vulnerable group of dying people-all of which are lessons that can be applied to EOL care in challenging settings beyond the walls of prison.